Continuum Extends Your Reach, Providing Expert Care to Complex Patients in the Home

If you have patients with multiple comorbidities, complicated pharmacologic needs, functional limitations, psychosocial limitations, or a combination of these and other health challenges, then you’re well aware that a clinic visit often isn’t enough to appropriately manage their care. In these instances, a home health provider can bridge the gap to ensure patients are following prescribed care plans and receive the support necessary for recovery and/or ongoing condition management.

University Medical Associates physician Daniel Becker, MD, relies on UVA Continuum Home Health Care to partner with him in caring for his complex patients. “I refer patients to Continuum two to three times per month,” he says. “It makes me feel better to know Continuum is there because the clinic isn’t available to these patients 24-7. Continuum makes sure IV antibiotics are administered, wounds are assessed and treated, that patients can get around the house without falling. Often these patients have limited health literacy, so their nurses go over everything, they help them organize their medications and educate the family.”

There are many home health providers in our area; however, few offer the breadth of services and expertise provided by Continuum Home Health. In addition to an extensive therapy program, Continuum provides psychiatric services, comprehensive pediatric care, including palliative care, and the full spectrum of home health infusion services.

“Because of the clinical expertise of our staff, we take patients others will not,” says Maggie Short, RN, MSN, NEA-BC, administrator for Community Services and Continuum Home Health Care . “A number of our therapists are doctoral-prepared and some [are] additionally certified in specialty areas. We also have a number of master’s-prepared clinicians, and our experience level is high for nurses in general.”

Continuum’s outcomes are a testament to the caliber of care provided. According to Centers for Medicare & Medicaid Services (CMS) Home Health Compare, Continuum consistently ranks higher than other providers in the region, with quality measures that surpass national and state averages in several key areas, including:

  • Pain treatment
  • Improved breathing
  • Prevention of pressure ulcers
  • Drug education and management
  • Fall risk assessment and prevention

A Joint Effort
Integral to Continuum’s successful outcomes is a collaborative relationship with referring providers. “We see physicians as partners,” says Short. “We’re their eyes and ears in the home, and the care we provide is under the physician’s supervision. They are our partners and we couldn’t do our job effectively without this interdisciplinary relationship.”

“Often Continuum nurses will find something I didn’t think of and I’m happy to get whatever help I can,” adds Becker. “It’s a collaborative process; they help assess the patient and we work out solutions together.”

While the lines of communication are always open, Short emphasizes that one of the Continuum team’s strengths is knowing when to involve the referring physician. “Because our staff has such a high level of experience, they know how to effectively triage a problem, how to intervene and when it’s best to call a doctor to step in and provide guidance,” she says.

Happy Patients, Happy Providers
Also important for a specialty in which providers are entering the home is the relationship between patient and caregiver. “A significant number of those who respond to our patient satisfaction surveys write personal notes about our team,” says Short. “This speaks to the intimate nature of care we provide and the relationships we build with our patients, starting with the first home visit.”

“Many of my patients think of Continuum as extended family,” says Becker. “These patients are readmitted to the hospital often and come back to Continuum again and again. More often than not, they will have the same nurse each time. That means a lot to me and it means a lot to the patient. It also says a lot about the organization; staffing is very stable there. They are professionals and people are happy to stay.”

Again, the data speaks for itself. Continuum has a five-star patient satisfaction rating according to Home Health Compare, scoring high marks in these and other key categories:

  • Professionalism
  • Communication
  • Would recommend to friends and family

“It takes a special kind of person to do home healthcare,” says Short. “The patient and family encounters are one-on-one, so that can be challenging in a busy day, but also very fulfilling because you get to see the direct impact you have on someone’s health. What could be more rewarding than that?”

Ready to Refer?
Continuum Home Health has a wide service area, shown here, and may accept referrals from any local hospital or community physician if their patients live within these geographic areas. To make a referral, call 434.984.CARE (2273) or 800.336.4040. You may also make a referral through Epic.